Upper Extremities

This site is not intended to provide diagnosis, treatment or medical advice. It is for informational purposes only and is not intended to take the place of a trained medial professional who knows the details of your medical history. Readers are advised to consult with a physician or other qualified health professional regarding any treatment.

Common Upper Extremity Characteristics:

• Internal Rotation of the Shoulders
• Extension or Flexion Contractures of the Elbow
• Flexion Contractures of the Wrists
• Thumb in Palm
• Extension or Flexion Contractures of Individual Fingers

Courses of Treatment:

Therapy

Occupational Therapy (OT) and/ or Physical Therapy (PT) should begin as soon as possible to increase passive range of motion (ROM). This can be done through a clinic or at home with your local Early Intervention Provider. Either way you should be taught stretches to do at home with your child. The first year is crucial to gain range back in any joint. Here are some representative common stretches to try. Always speak to your child’s health care professional before starting any kind of new routine. Read more about different Types of Therapy.

Stretches

A therapist should evaluate and identify joints requiring therapeutic attention, and then teach the caregiver how to correctly stretch the joints. The caregiver should practice stretching under supervision to insure proper technique to prevent accidental injuries, and to under exercise expectations. Issues such as previous surgeries, medication, bone density, etc., must be considered. Ranges of motion (ROM) exercises are individualized for each persons’ needs and should be directed by a therapist or a doctor. When performing stretches with a child, it is important to have the activity be fun and functional. Action songs, feeding, and dressing activities are all opportunities to naturally encourage upper body ROM activities.

Supporting the wrists in the best possible alignment should start as early as possible. Splinting the wrists and hands in infancy allows the soft tissue to lengthen and takes advantage of the infant’s flexibility. Splints may also be recommended for elbow or shoulder as well. Splints come in a wide variety of materials and shapes to help meet the individual’s specific needs. Sometimes several different orthotics are recommended at the same time, allowing greater stretch during inactive portions of the day while greater opportunity for functional activities at active times of the day. Here are some examples of types of upper extremity orthotics one may encounter:

Dynamic Splints: Dynamic splints push the joint into greater stretch when the limb relaxes. These orthotics typically are heavy and bulky so are not typically used for very small children. Dynamic splints are best used for joints that only move in one place such as an elbow. Some of the brands associated with this type of passive stretching include:

Bamboo Splint – a dynamic elbow splint for children with special needs that encourages extension of the elbow at more favorable angles in order to learn gross and fine motor skills as well as prevent undesired (oral/facial) interaction. Learn more: Bamboo Brace

Static Splints: Static Splints are designed to hold an extremity or a joint at the same angle each time the brace is put on. It may be designed to allow support, holding the joints for stability while allowing functional tasks or for stretch, holding the joint at end range alignment while the person relaxes in the stretch. Some examples of static splints are as follows:

Benik – Soft neoprene splints with a metal bar that can be manipulated to provide different amounts of stretch. Learn more: Benik

Bivalved cast: The limb is casted using plaster and/ or fiberglass casting material. Once hardened, the cast is carefully removed then finished with moleskin and velcro to allow the individual to wear the cast for times of stretch but remove it when it is not needed.

Custom Molded Splints – These are fabricated by an OT, a PT, or an Orthotist. Usually these splints are fabricated out of a thermoplastic material (plastic which is heated to allow it to mold easily) molded directly on the individual’s extremity. Often the splints are secured with velcro straps. These orthotics hold the joint in one position to allow a prolonged stretch

Joe Cool Splint – Thumb abduction splints made of soft, flexible neoprene and have an adjustable hook and loop closure system. They do have a latex component, and they can be hand washed in cold water (line dry). Learn more: Joe Cool

Surgery

Often with children who have little passive elbow flexion, surgery is recommended. Doctors often recommend an elbow capsular release as early as a year, but usually within the first 5 years of life. This may be delayed to ensure that the child is ambulatory before changing the power of straight elbows. This is a surgery done by releasing the tight fibrous structures in the elbow that constrict movement. After this if a child still does not develop any active flexion or enough functional passive flexion doctors may recommend a muscle transfer to provide elbow bending (flexion). This depends on the quality of the donor muscles as well. Common muscles used are the muscle from the back (latissimus dorsi), or a part of the triceps (referred to as a split triceps transfer). Most doctors will not perform this surgery on children under 4 or 5, because the child needs to participate in the therapy following the surgery to re-train the muscle motion, wear splints to protect the transfer, etc. Every doctor is different in how aggressively they treat upper extremity problems. Some doctors do not believe this surgery is effective at all and may not offer this as an option to their patients. In addition there are also several hand surgeries that can be performed. For children with a serious flexion contracture in their wrists a small triangular wedge of bone (wedge osteotomy) can be removed to bring the wrist to a more neutral resting position. There are also surgeries for thumb-in-palm, if extremely severe, and various finger surgeries. With the future of needing thumb position for management of touch screens and electronic devices for text messaging, thumb alignment is being looked at more critically than it ever before, in order to maximize long term function.

The Pediatric Hand Study Group met in Philadelphia in 2017.
Dr. Zlotolow led the symposium on arthrogryposis and led the discussion with an introduction to arthrogryposis.